Provider Demographics
NPI:1053353805
Name:WYNN, HENRY THOMAS JR (PA-C)
Entity type:Individual
Prefix:MR
First Name:HENRY
Middle Name:THOMAS
Last Name:WYNN
Suffix:JR
Gender:M
Credentials:PA-C
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Mailing Address - Street 1:SINAI CARDIOVASCULAR FACULTY GROUP PRACTICE
Mailing Address - Street 2:5051 GREENSPRING AVE. SUITE 304
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209
Mailing Address - Country:US
Mailing Address - Phone:106-017-7904
Mailing Address - Fax:410-601-8704
Practice Address - Street 1:SINAI CARDIOVASCULAR FACULTY GROUP PRACTICE
Practice Address - Street 2:5051 GREENSPRING AVE. SUITE 304
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209
Practice Address - Country:US
Practice Address - Phone:106-017-7904
Practice Address - Fax:410-601-8704
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2020-05-11
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Provider Licenses
StateLicense IDTaxonomies
MDC00420363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
S60207Medicare UPIN
MD407WMedicare PIN